Canadian doctors urged to limit testing to contain costs

Canadian doctors are under increasing pressure to think twice before reflexively ordering some tests and procedures as evidence mounts of the costs of unnecessary testing to the health-care system and to the well-being of patients.

Eight Canadian medical societies are set to unveil in April lists of diagnostic tests and other procedures they will urge their members not to perform unless patients exhibit symptoms that are a "red flag," according to a commentary published on Tuesday in the Canadian Medical Association Journal.

Dubbed Choosing Wisely Canada, the campaign piggybacks on a U.S. effort that identified dozens of tests and procedures as of little or no value, including imaging for uncomplicated headaches and lower back pain, pap smears for women who have had hysterectomies or are under the age of 21; routine check-ups for healthy adults; cancer screening for adults expected to live less than 10 years; and daily finger glucose testing for Type 2 diabetics who are not taking insulin.

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"[Unnecessary testing] is a very large problem," said Charles Wright, a past chair of the Ontario Health Technology Advisory Committee, which recommends medical treatments the province should adopt or discard.

"We've known about it for about three decades now, but it's only in the last few years that we seem to be waking up to how serious the issue is."

Some of these tests are already on the radar of Canada's premiers. First ministers agreed last summer to adopt guidelines for the appropriate use of medical imaging for lower back pain, headaches and minor head injuries, a move they estimated could help save $220-million of the more $2.2-billion spent annually on diagnostic imaging across the country.

The premiers vowed to give other tests a second look, too.

"It's a pretty big problem … We're great at adding new things, but rarely do we actually delist something that has become obsolete," Alberta Health Minister Fred Horne said in an interview on Tuesday.

"To get where we need to go in our province and in order to make the health-care system sustainable, this has to be about an awful lot more than a conversation."

But a conversation is where it needs to begin, according to Wendy Levinson, co-author of the CMAJ commentary and chair of the Department of Medicine at the University of Toronto.

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"We're trying to change a culture," she said. "When patients go to doctors, they frequently expect their doctor to order a test, give them a prescription or order an imaging procedure. Physicians also feel like patients won't feel satisfied unless they do those things."

Limiting tests can be a sensitive subject, one that sparks fears of health-care rationing.

That is why proponents of the Choosing Wisely approach are tiptoeing gingerly, focusing on the core message that unnecessary tests and procedures are bad for patients' health.

They are not calling for any services to be delisted from public medical coverage, and they are steering clear of controversial screening procedures such as mammograms, the efficacy of which was questioned last week in a hotly debated Canadian study.

"We strongly feel that this is about good medicine, not about cost reduction," said Dr. Levinson, who is also chair of Choosing Wisely Canada, which is supported by the Canadian Medical Association and at least 24 specialty medical organizations.

An article published last week in the New England Journal of Medicine largely praised the U.S. Choosing Wisely effort, but pointed out that "participating societies generally named other specialties' services as low-value."

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Such groups in Canada will release lists only for their own specialties. Recommendations are expected from organizations representing general surgeons, radiologists, cardiovascular surgeons, geriatricians, family doctors, orthopedic specialists, rheumatologists and practitioners of internal medicine.

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